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Rigamonti A, McLaren AT, Mazer CD, Nix K, Ragoonanan T, Freedman J, Harrington A, Hare GMT. Storage of strain-specific rat blood limits cerebral tissue oxygen delivery during acute fluid resuscitation. Br J Anaesth 2008; 100:357-64. [PMID: 18234679 DOI: 10.1093/bja/aem401] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The effect of blood storage on tissue oxygen delivery has not been clearly defined. Some studies demonstrate reduced microvascular oxygen delivery, whereas others do not. We hypothesize that storage of rat blood will limit its ability to deliver oxygen to cerebral tissue. METHODS Anaesthetized rats underwent haemorrhage (18 ml kg(-1)) and resuscitation with an equivalent amount of fresh or 7 day stored strain-specific whole blood. Arterial blood gases, co-oximetry, red cell counts and indices, and blood smears were performed. Hippocampal tissue oxygen tension (PBr(O2)), regional cerebral blood flow (rCBF), and mean arterial pressure (MAP) were measured before and for 60 min after resuscitation (n=6). Data [mean (SD)] were analysed by anova. RESULTS After 7 days, there was a significant reduction in pH, Pa(O2), an increase in Pa(CO2), but no detectable plasma haemoglobin in stored rat blood. Stored red blood cell morphology demonstrated marked echinocytosis, but no haemolysis in vitro. MAP and PBr(O2) in both groups decreased after haemorrhage. Resuscitation with stored blood returned MAP [92 (SD 16) mm Hg] and PBr(O2) [3.2 (0.7) kPa] to baseline, whereas rCBF remained stable [1.2 (0.1)]. Resuscitation with fresh blood returned MAP to baseline [105 (16) mm Hg] whereas both PBr(O2) [5.6 (1.5) kPa] and rCBF [1.9 (0.4)] increased significantly (P<0.05 for both, relative to baseline and stored blood group). There was no evidence of haemolysis in vivo. CONCLUSIONS Although resuscitation with stored blood restored cerebral oxygen delivery to baseline, fresh blood produced a greater increase in both PBr(O2) and rCBF. These data support the hypothesis that storage limits the ability of RBC to deliver oxygen to brain tissue.
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Affiliation(s)
- A Rigamonti
- Department of Anaesthesia, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8
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Abstract
Tissue oxygen delivery depends on red blood cell (RBC) content and RBC flow regulation in the microcirculation. The important role of the RBC in tissue oxygenation is clear from anaemia and the use of RBC transfusion which has saved many lives. Whether RBC transfusion actually restores tissue oxygenation is difficult to determine due to the lack of appropriate clinical monitoring techniques. Some patients with restored haemoglobin levels and stable haemodynamics still develop tissue hypoxia, emphasizing that, in addition to global parameters, local microcirculatory control mechanisms are also important in the restoration of tissue oxygenation. Both clinical and animal experimental studies have indicated that storage of RBC diminishes their ability to oxygenate the tissue. Several intrinsic RBC parameters that change during storage and might influence tissue oxygenation will be mentioned. The release of vasodilators from RBC that will alter blood flow during hypoxia, mediated by haemoglobin in the RBC that functions as an oxygen sensor, could be impaired during storage. A better understanding of hypoxia-induced vasodilator release from RBC might become a potential target for drug development and improve tissue oxygenation after transfusion.
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Affiliation(s)
- N J H Raat
- Vascular Medicine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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53
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The Critically III Red Blood Cell. Intensive Care Med 2007. [DOI: 10.1007/978-0-387-49518-7_72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Recent studies have underscored questions about the balance of risk and benefit of RBC transfusion. A better understanding of the nature and timing of molecular and functional changes in stored RBCs may provide strategies to improve the balance of benefit and risk of RBC transfusion. We analyzed changes occurring during RBC storage focusing on RBC deformability, RBC-dependent vasoregulatory function, and S-nitrosohemoglobin (SNO-Hb), through which hemoglobin (Hb) O(2) desaturation is coupled to regional increases in blood flow in vivo (hypoxic vasodilation). Five hundred ml of blood from each of 15 healthy volunteers was processed into leukofiltered, additive solution 3-exposed RBCs and stored at 1-6 degrees C according to AABB standards. Blood was subjected to 26 assays at 0, 3, 8, 24 and 96 h, and at 1, 2, 3, 4, and 6 weeks. RBC SNO-Hb decreased rapidly (1.2 x 10(-4) at 3 h vs. 6.5 x 10(-4) (fresh) mol S-nitrosothiol (SNO)/mol Hb tetramer (P = 0.032, mercuric-displaced photolysis-chemiluminescence assay), and remained low over the 42-day period. The decline was corroborated by using the carbon monoxide-saturated copper-cysteine assay [3.0 x 10(-5) at 3 h vs. 9.0 x 10(-5) (fresh) mol SNO/mol Hb]. In parallel, vasodilation by stored RBCs was significantly depressed. RBC deformability assayed at a physiological shear stress decreased gradually over the 42-day period (P < 0.001). Time courses vary for several storage-induced defects that might account for recent observations linking blood transfusion with adverse outcomes. Of clinical concern is that SNO levels, and their physiological correlate, RBC-dependent vasodilation, become depressed soon after collection, suggesting that even "fresh" blood may have developed adverse biological characteristics.
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Almac E, Ince C. The impact of storage on red cell function in blood transfusion. Best Pract Res Clin Anaesthesiol 2007; 21:195-208. [PMID: 17650772 DOI: 10.1016/j.bpa.2007.01.004] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Despite the common use of red-blood-cell transfusions in clinical practice, actual beneficial effects of red blood cells have never been demonstrated. On the contrary, several studies suggest that red-blood-cell transfusions are associated with higher risks of morbidity and mortality. The effects of the duration of storage on the efficacy of red blood cells have therefore been questioned in a number of studies. Recent insights into the physiology of red blood cells such as the role of the hypoxia-induced vasodilator-releasing function of red blood cells--is discussed in relation to the controversy surrounding the use of blood transfusions in clinical practice.
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Affiliation(s)
- Emre Almac
- Clinical Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Vincent JL, Sakr Y, De Backer D, Van der Linden P. Efficacy of allogeneic red blood cell transfusions. Best Pract Res Clin Anaesthesiol 2007; 21:209-19. [PMID: 17650773 DOI: 10.1016/j.bpa.2007.01.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The majority of intensive care unit (ICU) patients will receive a blood transfusion at some point during the course of their ICU stay, generally in an attempt to increase oxygen delivery and hence tissue oxygenation. The efficacy of red blood cell (RBC) transfusion can be evaluated through its effects on patient mortality or morbidity, or more simply by its effects on tissue oxygenation. Review of the available literature shows controversial results, with some studies showing that RBC transfusion may be efficacious while others do not. The true challenge lies in determining which patients will benefit from transfusion and those in whom it may be safe to delay or withhold transfusion. In this article, several key factors influencing the systemic and regional efficacy of blood transfusion will be reviewed.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium.
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57
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Sakr Y, Chierego M, Piagnerelli M, Verdant C, Dubois MJ, Koch M, Creteur J, Gullo A, Vincent JL, De Backer D. Microvascular response to red blood cell transfusion in patients with severe sepsis. Crit Care Med 2007; 35:1639-44. [PMID: 17522571 DOI: 10.1097/01.ccm.0000269936.73788.32] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Microvascular alterations may play a role in the development of multiple organ failure in severe sepsis. The effects of red blood cell transfusions on microvascular perfusion are not well defined. We investigated the effects of red blood cell transfusion on sublingual microvascular perfusion in patients with sepsis. DESIGN Prospective, observational study. SETTING A 31-bed, medical-surgical intensive care unit of a university hospital. PATIENTS Thirty-five patients with severe sepsis requiring red blood cell transfusions. INTERVENTIONS Transfusion of one to two units of leukocyte-reduced red blood cells. MEASUREMENTS AND MAIN RESULTS The sublingual microcirculation was assessed with an Orthogonal Polarization Spectral device before and 1 hr after red blood cell transfusion. Red blood cell transfusions increased hemoglobin concentration from 7.1 (25th-75th percentile, 6.7-7.6) to 8.1 (7.5-8.6) g/dL (p < .01), mean arterial pressure from 75 (69-89) to 82 (75-90) mm Hg (p < .01), and oxygen delivery from 349 (278-392) to 391 (273-473) mL/min.M (p < .001). Microvascular perfusion was not significantly altered by transfusion, but there was considerable interindividual variation. The change in capillary perfusion after transfusion correlated with baseline capillary perfusion (Spearman-rho = -.49; p = .003). Capillary perfusion was significantly lower at baseline in patients who increased their capillary perfusion by >8% compared with those who did not (57 [52-64] vs. 75 [70-79]; p < .01), while hemodynamic and global oxygen transport variables were similar in the two groups. Red blood cell storage time had no influence on the microvascular response to red blood cell transfusion. CONCLUSIONS The sublingual microcirculation is globally unaltered by red blood cell transfusion in septic patients; however, it can improve in patients with altered capillary perfusion at baseline.
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Affiliation(s)
- Yasser Sakr
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Brussels, Belgium
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Gonzalez AM, Yazici I, Kusza K, Siemionow M. Effects of fresh versus banked blood transfusions on microcirculatory hemodynamics and tissue oxygenation in the rat cremaster model. Surgery 2007; 141:630-9. [PMID: 17462463 DOI: 10.1016/j.surg.2006.09.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 08/30/2006] [Accepted: 09/10/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Blood transfusion is recommended to prevent the harmful effects of tissue hypoxia. Whether transfusion alleviates hypoxia at the microcirculatory level is unknown. The objective of this study was to determine whether the effects of fresh blood transfusion on microcirculatory hemodynamics after blood loss are preferable to the effects of banked blood transfusion. METHODS Intravital microcirculatory hemodynamics was observed in the rat cremaster muscle flap by observers who were not blinded. Lewis rats were divided into 6 groups (8 rats per group): (1) untreated control; (2) blood withdrawal only (1 mL); (3) blood withdrawal and transfusion of rat fresh blood (1 mL); (4) blood withdrawal and transfusion with 1-day rat banked blood (1 mL); (5) blood withdrawal and transfusion with 1-week rat banked blood (1 mL); and (6) blood withdrawal and transfusion with 2-week rat banked blood (1 mL). Red blood cell velocity, blood flow, vessel diameter, functional capillary perfusion, red blood cell deformability, leukocytes (granulocytes and lymphocytes), and tissue oxygenation levels were monitored before transfusion and for 5 hours afterward. Histology was performed to evaluate tissue inflammation (hematoxylin and eosin [H&E] stain and myeloperoxidase [MPO] immunoassay) and hypoxia (Hypoxyprobe assay). RESULTS Fresh- and banked blood-transfused groups did not differ in vessel diameters or red blood cell velocities. Functional capillary density was greater in the fresh blood group when compared to 1- and 2-week banked blood-transfused groups. The overall number of granulocytes (rolling, sticking, and transmigrated) was greater in all groups after transfusion (P < .001). Rats transfused with banked blood had a greater number of rolling lymphocytes and more inflammation. Tissue oxygenation levels were improved after fresh blood transfusion in comparison to banked blood (9.5 mm Hg vs 8 mm Hg, P = .02). CONCLUSIONS Fresh blood transfusion is more effective in relieving effects of microcirculatory hypoxia. Banked blood, in particular 2-week stored blood, has limited capacity of improving tissue oxygenation.
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Fu SL, Bluth MH. Monitoring efficacy of red blood cell transfusion in sepsis by sublingual microvascular perfusion: a tongue speaks without words. Crit Care Med 2007; 35:1773-4. [PMID: 17581359 DOI: 10.1097/01.ccm.0000269396.54140.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ferraris VA, Ferraris SP, Saha SP, Hessel EA, Haan CK, Royston BD, Bridges CR, Higgins RSD, Despotis G, Brown JR, Spiess BD, Shore-Lesserson L, Stafford-Smith M, Mazer CD, Bennett-Guerrero E, Hill SE, Body S. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007; 83:S27-86. [PMID: 17462454 DOI: 10.1016/j.athoracsur.2007.02.099] [Citation(s) in RCA: 543] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Revised: 01/21/2007] [Accepted: 02/08/2007] [Indexed: 01/24/2023]
Abstract
BACKGROUND A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes. METHODS We reviewed all available published evidence related to blood conservation during cardiac operations, including randomized controlled trials, published observational information, and case reports. Conventional methods identified the level of evidence available for each of the blood conservation interventions. After considering the level of evidence, recommendations were made regarding each intervention using the American Heart Association/American College of Cardiology classification scheme. RESULTS Review of published reports identified a high-risk profile associated with increased postoperative blood transfusion. Six variables stand out as important indicators of risk: (1) advanced age, (2) low preoperative red blood cell volume (preoperative anemia or small body size), (3) preoperative antiplatelet or antithrombotic drugs, (4) reoperative or complex procedures, (5) emergency operations, and (6) noncardiac patient comorbidities. Careful review revealed preoperative and perioperative interventions that are likely to reduce bleeding and postoperative blood transfusion. Preoperative interventions that are likely to reduce blood transfusion include identification of high-risk patients who should receive all available preoperative and perioperative blood conservation interventions and limitation of antithrombotic drugs. Perioperative blood conservation interventions include use of antifibrinolytic drugs, selective use of off-pump coronary artery bypass graft surgery, routine use of a cell-saving device, and implementation of appropriate transfusion indications. An important intervention is application of a multimodality blood conservation program that is institution based, accepted by all health care providers, and that involves well thought out transfusion algorithms to guide transfusion decisions. CONCLUSIONS Based on available evidence, institution-specific protocols should screen for high-risk patients, as blood conservation interventions are likely to be most productive for this high-risk subset. Available evidence-based blood conservation techniques include (1) drugs that increase preoperative blood volume (eg, erythropoietin) or decrease postoperative bleeding (eg, antifibrinolytics), (2) devices that conserve blood (eg, intraoperative blood salvage and blood sparing interventions), (3) interventions that protect the patient's own blood from the stress of operation (eg, autologous predonation and normovolemic hemodilution), (4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly, (5) a multimodality approach to blood conservation combining all of the above.
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Tinmouth A, Fergusson D, Yee IC, Hébert PC. Clinical consequences of red cell storage in the critically ill. Transfusion 2006; 46:2014-27. [PMID: 17076859 DOI: 10.1111/j.1537-2995.2006.01026.x] [Citation(s) in RCA: 436] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Red cell (RBC) transfusions are a potentially life-saving therapy employed during the care of many critically ill patients to replace losses in hemoglobin to maintain oxygen delivery to vital organs. During storage, RBCs undergo a series of biochemical and biomechanical changes that reduce their survival and function. Additionally, accumulation of other biologic by-products of RBC preservation may be detrimental to recipients of blood transfusions. Laboratory studies and an increasing number of observational studies have raised the possibility that prolonged RBC storage adversely affects clinical outcomes. In this article, the laboratory and animal experiments evaluating changes to RBCs during prolonged storage are reviewed. Subsequently, the clinical studies that have evaluated the clinical consequences of prolonged RBC storage are reviewed. These data suggest a possible detrimental clinical effect associated with the transfusion of stored RBCs; randomized clinical trials further evaluating the clinical consequences of transfusing older stored RBCs are required.
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Affiliation(s)
- Alan Tinmouth
- Center for Transfusion and Critical Care Research, Clinical Epidemiology Unit, Critical Care Program, University of Ottawa and Ottawa Health Research Institute, Ottawa, Ontario, Canada
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62
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von Heymann C, Sander M, Foer A, Heinemann A, Spiess B, Braun J, Krämer M, Grosse J, Dohmen P, Dushe S, Halle J, Konertz WF, Wernecke KD, Spies C. The impact of an hematocrit of 20% during normothermic cardiopulmonary bypass for elective low risk coronary artery bypass graft surgery on oxygen delivery and clinical outcome--a randomized controlled study [ISRCTN35655335]. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R58. [PMID: 16606474 PMCID: PMC1550910 DOI: 10.1186/cc4891] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Revised: 03/04/2006] [Accepted: 03/14/2006] [Indexed: 11/16/2022]
Abstract
Introduction Cardiopulmonary bypass (CPB) induces hemodilutional anemia, which frequently requires the transfusion of blood products. The objective of this study was to evaluate oxygen delivery and consumption and clinical outcome in low risk patients who were allocated to an hematocrit (Hct) of 20% versus 25% during normothermic CPB for elective coronary artery bypass graft (CABG) surgery. Methods This study was a prospective, randomized and controlled trial. Patients were subjected to normothermic CPB (35 to 36°C) and were observed until discharge from the intensive care unit (ICU). Outcome measures were calculated whole body oxygen delivery, oxygen consumption and clinical outcome. A nonparametric multivariate analysis of variance for repeated measurements and small sample sizes was performed. Results In a total of 54 patients (25% Hct, n = 28; 20% Hct, n = 26), calculated oxygen delivery (p = 0.11), oxygen consumption (p = 0.06) and blood lactate (p = 0.60) were not significantly different between groups. Clinical outcomes were not different between groups. Conclusion These data indicate that an Hct of 20% during normothermic CPB maintained calculated whole body oxygen delivery above a critical level after elective CABG surgery in low risk patients. The question of whether a transfusion trigger in excess of 20% Hct during normothermic CPB is still supported requires a larger prospective and randomized trial.
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Affiliation(s)
- Christian von Heymann
- Department of Anesthesiology and Intensive Care Medicine, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
| | - Michael Sander
- Department of Anesthesiology and Intensive Care Medicine, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
| | - Achim Foer
- Department of Anesthesiology and Intensive Care Medicine, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
| | - Anja Heinemann
- Department of Anesthesiology and Intensive Care Medicine, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
| | - Bruce Spiess
- Department of Anesthesiology and the Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES), Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Jan Braun
- Department of Anesthesiology and Intensive Care Medicine, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
| | - Michael Krämer
- Department of Anesthesiology and Intensive Care Medicine, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
| | - Joachim Grosse
- Department of Anesthesiology and Intensive Care Medicine, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
| | - Pascal Dohmen
- Department of Cardiovascular Surgery, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
| | - Simon Dushe
- Department of Cardiovascular Surgery, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
| | - Jürgen Halle
- Department of Cardiovascular Surgery, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
| | - Wolfgang F Konertz
- Department of Cardiovascular Surgery, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
| | - Klaus-Dieter Wernecke
- Department of Cardiovascular Surgery, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Charité – University Hospital Berlin, Charité Campus Mitte, Berlin, Germany
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Intaglietta M, Cabrales P, Tsai AG. MICROVASCULAR PERSPECTIVE OF OXYGEN-CARRYING AND -NONCARRYING BLOOD SUBSTITUTES. Annu Rev Biomed Eng 2006; 8:289-321. [PMID: 16834558 DOI: 10.1146/annurev.bioeng.8.061505.095713] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The development of an alternative to natural blood has evolved from the initial goal of replicating blood properties to the current objective of formulating a fluid that can be used to replace blood while preserving microvascular function and delivering oxygen. The properties of this fluid are counterintuitive and different from blood because it has high viscosity, oxygen affinity, and a low oxygen carrier concentration when compared with blood. The optimal oxygen carrier devised presently is poly-ethylene-conjugated human hemoglobin, a material demonstrated to be vasoinactive and void of the toxicities present in previous hemoglobin formulations. A feature of this material is that it is effective in small quantities, and therefore amplifies the equivalent supply of blood derived from blood donations.
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Affiliation(s)
- Marcos Intaglietta
- Department of Bioengineering, University of California, San Diego, La Jolla, California 92093-0412, USA.
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Abstract
PURPOSE OF REVIEW As a result of advances in pathogen testing and transfusion standards over the last decade, the risk of disease transmission through allogeneic blood transfusions has decreased markedly. The effects of allogeneic blood transfusions on the immune system, however, have received more attention, as they appear to influence outcome. The following review summarizes the effects of allogeneic blood transfusions on selected outcome parameters and the influence of white blood cell reduction on these parameters. RECENT FINDINGS Adverse effects of allogeneic blood transfusions on outcome variables such as postoperative infection, cancer recurrence, pulmonary function, length of stay, and mortality have been shown in multiple trials, but most were not randomized or blinded. One proposed approach to reduce unwanted side-effects is to reduce the donor's white blood cell count before transfusion. This can be done either by individual bedside filtration or by pre-storage (or post-storage) universal white blood cell reduction. Studies investigating this approach have yielded conflicting results. SUMMARY Although the results of a number of studies suggest a negative impact of allogeneic blood transfusions on immune function and consequently outcome parameters, this has not been proven in rigorously controlled randomized trial, or in meta-analyses. Reduction of white blood cells might be beneficial in selected patient populations, but at this time does not appear warranted in the general surgical population. As universal white blood cell reduction is a very costly process, it probably should not be implemented until such a benefit is proven.
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Affiliation(s)
- Danja Strumper-Groves
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia 22908-0710, USA.
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66
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Raat NJH, Berends F, Verhoeven AJ, de Korte D, Ince C. The age of stored red blood cell concentrates at the time of transfusion. Transfus Med 2005; 15:419-23. [PMID: 16202057 DOI: 10.1111/j.1365-3148.2005.00606.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In the past decade, studies suggesting a reduced oxygen delivery by stored red blood cell concentrates (RBCCs) have initiated a discussion about the use of fresh versus old blood. We determined whether old RBCCs represent a significant part of the total of RBCCs issued. The age of RBCCs at the time of transfusion was determined in 74 084 units during a 5-year period in the Academic Medical Center, a main Dutch University Hospital. The mean (+/-SD) storage time of the total number of transfused RBCC was 19.4 +/- 7.0 days, and 37% were older than 3 weeks. As more than one-third of the transfused RBCC units are stored for longer than 3 weeks, the research examining differences in oxygen delivery between fresh and stored RBCC is relevant for packed RBC transfusion practice.
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Affiliation(s)
- N J H Raat
- Department of Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Arslan E, Sierko E, Waters JH, Siemionow M. Microcirculatory hemodynamics after acute blood loss followed by fresh and banked blood transfusion. Am J Surg 2005; 190:456-62. [PMID: 16105536 DOI: 10.1016/j.amjsurg.2005.05.041] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2004] [Revised: 05/02/2005] [Accepted: 05/02/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND Red blood cell (RBC) conformational changes occur when blood is stored. This study was designed to be a preliminary evaluation to assess how these changes affect the microcirculation. METHODS The rat cremaster muscle flap model was used to evaluate in vivo microcirculatory changes after withdrawal of 1 mL blood with subsequent administration of fresh blood (group I, n=6) and banked blood (group II, n=6). Each group underwent a 3-stage evaluation: baseline, after blood withdrawal, and after transfusion. Using intravital microscopy, RBC velocity, vessel diameter, functional capillary perfusion, and leukocyte-endothelial interactions were noted. RESULTS After blood withdrawal, changes in RBC velocity, vessel diameter, functional capillary perfusion, and number of activated leukocytes were observed in both groups, but these changes were more significant in stored blood compared with fresh blood (P<or=.05). CONCLUSIONS Further work is needed to validate these findings, but these preliminary data suggest that stored blood may have a deleterious effect on the microcirculation.
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Affiliation(s)
- Emrah Arslan
- Department of Plastic Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA
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Schwarte LA, Fournell A, van Bommel J, Ince C. Redistribution of intestinal microcirculatory oxygenation during acute hemodilution in pigs. J Appl Physiol (1985) 2005; 98:1070-5. [PMID: 15475597 DOI: 10.1152/japplphysiol.00861.2004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Acute normovolemic hemodilution (ANH) compromizes intestinal microcirculatory oxygenation; however, the underlying mechanisms are incompletely understood. We hypothesized that contributors herein include redistribution of oxygen away from the intestines and shunting of oxygen within the intestines. The latter may be due to the impaired ability of erythrocytes to off-load oxygen within the microcirculation, thus yielding low tissue/plasma Po2 but elevated microcirculatory hemoglobin oxygen (HbO2) saturations. Alternatively, oxygen shunting may also be due to reduced erythrocyte deformability, hindering the ability of erythrocytes to enter capillaries. Anesthetized pigs underwent ANH (20, 40, 60, and 90 ml/kg hydroxyethyl starch; ANH group: n = 10; controls: n = 5). We measured systemic and mesenteric perfusion. Microvascular intestinal oxygenation was measured independently by remission spectrophotometry [microcirculatory HbO2 saturation (μHbO2)] and palladium-porphyrin phosphorescence quenching [microcirculatory oxygen pressure in plasma/tissue (μPo2)]. Microcirculatory oxygen shunting was assessed as the disparity between mucosal and mesenteric venous HbO2 saturation (HbO2-gap). Erythrocyte deformability was measured as shear stress-induced cell elongation (LORCA difractometer). ANH reduced hemoglobin concentration from 8.1 to 2.2 g/dl. Relative mesenteric perfusion decreased (decreased mesenteric/systemic perfusion fraction). A paralleled reduction occurred in mucosal μHbO2 (68 ± 2 to 41 ± 3%) and μPo2 (28 ± 1 to 17 ± 1 Torr). Thus the proposed constellation indicative for oxygen off-load deficits (sustained μHbO2 at decreased μPo2) did not develop. A twofold increase in the HbO2-gap indicated increasing intestinal microcirculatory oxygen shunting. Significant impairment in erythrocyte deformability developed during ANH. We conclude that reduced intestinal oxygenation during ANH is, in addition to redistribution of oxygen delivery away from the intestines, associated with oxygen shunting within the intestines. This shunting appears to be not primarily caused by oxygen off-load deficit but rather by oxygen/erythrocytes bypassing capillaries, wherein a potential contributor is impaired erythrocyte deformability.
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Affiliation(s)
- Lothar A Schwarte
- Department of Physiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
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69
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Torres Filho IP, Spiess BD, Pittman RN, Barbee RW, Ward KR. Experimental analysis of critical oxygen delivery. Am J Physiol Heart Circ Physiol 2005; 288:H1071-9. [DOI: 10.1152/ajpheart.00884.2004] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Systemic variables were evaluated with respect to O2 delivery to test the hypothesis that critical O2 delivery and critical Hb can be estimated by multiple variables collected simultaneously. Rats were subjected to transfusion with either fresh or stored blood and then subjected to stepwise isovolemic hemodilution. Critical levels were measured by the dual-regression method from plots of systemic variables against O2 delivery and Hb. Delivery was calculated from cardiac index and arterial O2 content. We found that 1) after hemodilution, O2 delivery changed in a nonlinear relationship with Hb; 2) critical delivery calculated using 30 different systemic variables was not statistically different from each other; 3) critical delivery and critical Hb were correlated but were not different between animals receiving fresh or stored blood; and 4) similar critical levels were found using a single variable from several animals and using several variables from the same subject. The best variables to estimate critical delivery were lactate, bicarbonate, base excess, O2 extraction ratio, expired CO2, pulse pressure, cardiac index, and systolic pressure. The data suggest that a multivariable analysis of critical delivery may help determine the physiological oxygenation boundary at the whole body level. This may assist in finding therapeutic triggers on an individual basis using systemic markers of the transition from aerobic to anaerobic metabolism.
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70
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Abstract
Nitric oxide (NO) was identified as a physiological mediator of vascular tone in 1987. NO produced by endothelial cells causes vasodilatation and also inhibits platelet aggregation and leucocyte adhesion. Red cells metabolize NO to nitrate but may possibly carry and release, or even produce, NO in hypoxic conditions. NO physiology may have important implications for transfusion medicine, ranging from adverse effects of haemoglobin substitutes to preservation of stored platelets and to detrimental effects of stored red cells.
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Affiliation(s)
- J P Wallis
- Department of Haematology, Freeman Hospital, High Heaton, Newcastle Upon Tyne, UK.
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71
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Raat NJ, Verhoeven AJ, Mik EG, Gouwerok CW, Verhaar R, Goedhart PT, de Korte D, Ince C. The effect of storage time of human red cells on intestinal microcirculatory oxygenation in a rat isovolemic exchange model*. Crit Care Med 2005; 33:39-45; discussion 238-9. [PMID: 15644646 DOI: 10.1097/01.ccm.0000150655.75519.02] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine whether the storage time of human leukodepleted red blood cell concentrates compromises intestinal microvascular oxygen concentration oxygen (muPo(2)) during isovolemic exchange transfusion at low hematocrit. DESIGN Prospective, randomized, controlled study. SETTING University research institute laboratory. SUBJECTS Male Wistar rats. INTERVENTIONS Intestinal muPo(2) was determined by Pd-porphyrin phosphorescence life-time measurements. MEASUREMENTS AND MAIN RESULTS Rats were brought near to a state of oxygen supply dependency by hemodilution with a pasteurized plasma protein solution to a hematocrit of 14.3 +/- 1.1% (n = 24). Subsequently, an isovolemic exchange transfusion with human leukodepleted red blood cells, stored for 2-6 days (fresh, n = 8), 2-3 wks (intermediate, n = 8), or 5-6 wks (old, n = 8), was performed to determine whether intestinal muPo(2) would be preserved. Immunologic reactions were avoided by washing the red blood cell concentrates three times before use. Isovolemic exchange with fresh and intermediate red blood cells maintained muPo(2) whereas old cells decreased muPo(2) with 26%. Subsequent transfusion with red blood cells (hematocrit approximately 60%) until reaching a hematocrit of 32.4 +/- 2.1 % (n = 24) increased intestinal muPo(2) in all three groups to the same extent between 28% and 32%. No changes in red blood cell deformability, as determined by a Laser-assisted Optical Rotational Cell Analyzer, could be demonstrated during 5 wks of storage. CONCLUSION This study shows that at low hematocrit, the oxygen-delivering capacity of human red blood cells stored 5-6 wks is reduced compared with fresh cells and red blood cells stored for an intermediate period. Although red blood cells stored for 2-3 wks are completely devoid of 2,3-diphosphoglycerate, their oxygen-delivering capacity to the intestines was the same as fresh red blood cells. Our study showed that red blood cell deformability was preserved during storage, suggesting that other mechanisms may account for the observed decrease in oxygen delivery by red blood cells stored 2-3 wks.
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Affiliation(s)
- N J Raat
- Department of Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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72
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Affiliation(s)
- Bruce D Spiess
- Department of Anesthesiology, VCUMC, Richmond, Virginia 23298-0695, USA.
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73
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Tsai AG, Cabrales P, Intaglietta M. Microvascular perfusion upon exchange transfusion with stored red blood cells in normovolemic anemic conditions. Transfusion 2004; 44:1626-34. [PMID: 15504169 DOI: 10.1111/j.0041-1132.2004.04128.x] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transfusions are intended to augment oxygen-carrying capacity. The ability of fresh and stored red blood cells (RBCs) to maintain microvascular perfusion and oxygen delivery to the tissue has not been directly measured. STUDY DESIGN AND METHODS Microvascular responses to exchange transfusion with fresh and stored RBCs after acute isovolemic hemodilution with a plasma expander were investigated with the hamster window chamber model. In-vivo functional capillary density (FCD), blood flow, and high-resolution oxygen distribution in microvascular networks were measured by noninvasive methods. RESULTS Exchange transfusion with an RBC suspension after a 60 percent isovolemic hemodilution with dextran 70 (6% MW = 70 kDa) resulted in a hematocrit of 18 percent (5.6 +/- 0.2 g/dL hemoglobin [Hb]). All other systemic variables were unchanged. Stored RBCs (28 days in citrate-phosphate-dextrose-adenine-1) resuspended in fresh frozen plasma matched to the Hct and Hb concentration were exchange transfused until 25 percent of the circulating RBCs were stored RBCs. Stored RBCs reduced microvascular flow and FCD by 63 and 54 percent, respectively, of the level achieved when fresh RBCs were exchange transfused. Microvascular oxygen extraction by the stored RBC was 54 percent lower than that of the fresh RBCs. The tissue oxygen levels were 3.5 and 14.4 mmHg for the stored and fresh RBCs, respectively. CONCLUSION Circulation of stored RBCs in a hemodiluted animal resulted in significantly malperfused and underoxygenated microvasculature that was not detectable at the systemic level.
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Affiliation(s)
- Amy G Tsai
- Department of Bioengineering, University of California at San Diego, La Jolla 92093-0412, USA.
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74
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Obara S, Iwama H. Prestorage leukocyte reduction prevents the formation of microaggregates that occlude artificial capillary vessels. J Crit Care 2004; 19:179-86. [PMID: 15484179 DOI: 10.1016/j.jcrc.2004.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The passage behavior of stored blood through an artificial microchannel system, as a model of capillary vessels, was examined. MATERIALS AND METHODS Using blood obtained from a total of 17 healthy volunteers, untreated and prestorage leukocyte reduced blood, or untreated and prestorage microfiltered (35 microm-pore size) blood were stored, and then the passage behavior through the microchannels was evaluated. Also, using blood from 16 patients stored for about 2 weeks, the effect of a leukocyte reduction filter, microfilter or mesh filter (175-210 microm-pore size) on the passage through the microchannels was examined. RESULTS Untreated blood passed through the microchannels immediately after blood collection, but after 1 week occlusion of the microchannels occurred. Prestorage leukocyte reduced blood, however, passed through the microchannels for up to 6 weeks. Occlusion of the microchannels occurred with both the untreated and prestorage microfiltered blood. Although filtration through a leukocyte reduction filter provided blood that can pass through the microchannels, occlusion occurred with blood filtered in other way. CONCLUSIONS The present results show that stored blood produces abundant microaggregates, potentially occluding capillary vessels. These microaggregates are not formed after prestorage leukocyte reduction or can be removed by use of a leukocyte reduction filter.
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Affiliation(s)
- Shinju Obara
- Department of Anesthesiology, Central Aizu General Hospital, Tsuruga-machi, Aizuwakamatsu City, Japan
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75
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Affiliation(s)
- Bruce D Spiess
- Department of Anesthesiology, VCUHS, Richmond, VA 23298, USA.
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76
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Notfall- und Massivtransfusion. TRANSFUSIONSMEDIZIN 2004. [DOI: 10.1007/978-3-662-10597-9_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Ho J, Sibbald WJ, Chin-Yee IH. Effects of storage on efficacy of red cell transfusion: When is it not safe? Crit Care Med 2003; 31:S687-97. [PMID: 14724467 DOI: 10.1097/01.ccm.0000099349.17094.a3] [Citation(s) in RCA: 188] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To review the literature on red blood cell storage and its relationship to the efficacy of transfusion. RESULTS Well-documented changes occur to the red blood cell product during ex vivo storage. These changes include a reduction in red blood cell deformability, altered red blood cell adhesiveness and aggregability, and a reduction in 2,3-diphosphoglycerate and ATP. Bioactive compounds with proinflammatory effects also accumulate in the storage medium. These changes reduce posttransfusion viability of red blood cells. The clinical effects beyond posttransfusion viability are uncertain, but a growing body of evidence suggests that the storage lesion may reduce tissue oxygen availability, have proinflammatory and immunomodulatory effects, and influence morbidity and mortality. There are no published randomized, control trials examining the effect of storage duration on morbidity and mortality. Leukoreduction improves the quality of stored red blood cell products and in some studies has been shown to reduce morbidity and mortality. CONCLUSION Although storage duration influences the quality of red blood cell product, there is currently insufficient evidence to advocate shorter storage periods for red blood cell products.
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Affiliation(s)
- Juliet Ho
- Departmentof Medicine, The University of Western Ontario, London, Canada
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Abstract
The introduction of recombinant human erythropoietin (RHuEPO) has revolutionised the treatment of patients with anaemia of chronic renal disease. Clinical studies have demonstrated that RHuEPO is also useful in various non-uraemic conditions including haematological and oncological disorders, prematurity, HIV infection, and perioperative therapies. Besides highlighting both the historical and functional aspects of RHuEPO, this review discusses the applications of RHuEPO in clinical practice and the potential problems of RHuEPO treatment.
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Affiliation(s)
- T Ng
- Phase One Clinical Trials Unit Ltd, Plymouth, UK.
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81
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Wagner CT, Martowicz ML, Livesey SA, Connor J. Biochemical stabilization enhances red blood cell recovery and stability following cryopreservation. Cryobiology 2002; 45:153-66. [PMID: 12482381 DOI: 10.1016/s0011-2240(02)00124-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Glycerolized red blood cells (RBC) are approved for long-term cryopreservation. However, the need to remove the glycerol cryoprotectant prior to transfusion has limited the usefulness of this cryopreservation method. This report describes using non-cryoprotectant biochemical stabilization techniques to substitute for the standard glycerol cryoprotectant. The glycerolized RBC method was compared to a newly developed LC-V method that combines transfusable cryoprotectants (hydroxyethyl starch and dextran) and specific non-cryoprotectant biochemical stabilizers (nicotinamide, nifedipine, and flurbiprofen). Results demonstrate that the biochemical stabilizers significantly reduce cryopreservation-induced hemolysis compared to cryopreservation in their absence and that thaw hemolysis levels approach those of standard 40% (w/v) glycerolized RBC (3.1+/-0.2% for 40% glycerol compared to 8.7+/-0.9% for the LC-V protocol). Furthermore, LC-V cryopreserved RBC exhibit a significantly enhanced post-thaw stability compared to glycerolized RBC as determined by osmotic fragility index (0.557+/-0.034 for 40% glycerol compared to 0.478+/-0.016 for the LC-V protocol). Analysis of biochemically stabilized RBC proteins revealed a transient translocation of carbonic anhydrase to the membrane fraction. However, the enhanced RBC recovery and stability could not be attributed to this event. Finally, DSC analysis demonstrated that the biochemical stabilizers of the LC-V process were not functioning as surrogate cryoprotectants in that they did not affect the quantity or quality of ice formed. Overall, this work demonstrates that cryopreservation-induced RBC damage may be corrected or prevented through specific biochemical stabilization and represents a significant step toward a directly transfusable cryopreserved RBC product.
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Affiliation(s)
- Christopher T Wagner
- Cell Biology Research, LifeCell Corporation, One Millennium Way, Branchburg, NJ 08876, USA.
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Ball J, Venn R, Williams G, Forni L. 22nd International Symposium on Intensive Care and Emergency Medicine, Brussels, Belgium, 19-22 March 2002. Crit Care 2002; 6:264-70. [PMID: 12133191 PMCID: PMC137453 DOI: 10.1186/cc1502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jonathan Ball
- Department of Anaesthesia & Intensive Care, St George's Hospital Medical School, University of London, UK.
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